title: Evaluation of clinical pharmacist recommendations in the geriatric ward of a Belgian university hospital.
abstract: OBJECTIVE
  To evaluate the type, acceptance rate, and clinical relevance of clinical pharmacist recommendations at the geriatric ward of the Ghent university hospital.
  
  
  METHODS
  The clinical pharmacist evaluated drug use during a weekly 2-hour visit for a period of 4 months and, if needed, made recommendations to the prescribing physician. The recommendations were classified according to type, acceptance by the physician, prescribed medication, and underlying drug-related problem. Appropriateness of prescribing was assessed using the Medication Appropriateness Index (MAI) before and after the recommendations were made. Two clinical pharmacologists and two clinical pharmacists independently and retrospectively evaluated the clinical relevance of the recommendations and rated their own acceptance of them.
  
  
  RESULTS
  The clinical pharmacist recommended 304 drug therapy changes for 100 patients taking a total of 1137 drugs. The most common underlying drug-related problems concerned incorrect dose, drug-drug interaction, and adverse drug reaction, which appeared most frequently for cardiovascular drugs, drugs for the central nervous system, and drugs for the gastrointestinal tract. The most common type of recommendation concerned adapting the dose, and stopping or changing a drug. In total, 59.7% of the recommendations were accepted by the treating physician. The acceptance rate by the evaluators ranged between 92.4% and 97.0%. The mean clinical relevance of the recommendations was assessed as possibly important (53.4%), possibly low relevance (38.1%), and possibly very important (4.2%). A low interrater agreement concerning clinical relevance between the evaluators was found: kappa values ranged between 0.15 and 0.25. Summated MAI scores significantly improved after the pharmacist recommendations, with mean values decreasing from 9.3 to 6.2 (P < 0.001).
  
  
  CONCLUSIONS
  In this study, the clinical pharmacist identified a high number of potential drug-related problems in older patients; however, the acceptance of the pharmacotherapy recommendations by the treating physician was lower than by a panel of evaluators. This panel, however, rated most recommendations as possibly important and as possibly having low relevance, with low interrater reliability. As the appropriateness of prescribing seemed to improve with decreased MAI scores, clinical pharmacy services may contribute to the optimization of drug therapy in older inpatients.
authors.affiliation: Department of Pharmacy, Ghent University Hospital, Ghent, Belgium. annemie.somers@uzgent.be
authors.forename: Annemie
authors.initials: A
authors.lastname: Somers
authors.forename: Hugo
authors.initials: H
authors.lastname: Robays
authors.forename: Peter
authors.initials: P
authors.lastname: De Paepe
authors.forename: Georges
authors.initials: G
authors.lastname: Van Maele
authors.forename: Katrina
authors.initials: K
authors.lastname: Perehudoff
authors.forename: Mirko
authors.initials: M
authors.lastname: Petrovic
mesh_terms: D000369:Aged, 80 and over; D001530:Belgium; D004347:Drug Interactions; D017723:Drug Utilization Review; D005260:Female; D005853:Geriatrics / Q000592:standards*; D006785:Hospitals, University; D006801:Humans; D057970:Inappropriate Prescribing; D007297:Inpatients; D008297:Male; D010593:Pharmaceutical Services / Q000592:standards*; D010595:Pharmacists / Q000592:standards*; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D018709:Statistics, Nonparametric
keywords: clinical pharmacist; drug-related problems; geriatric inpatients